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Running Head: SHOOTING DOWN

Shooting Down the United States Heroin Epidemic

Bailey M. Nixon

Glen Allen High School

Introduction
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Within the last several decades, it is clear that America is experiencing an epidemic

unlike any other; the distribution and use of heroin in the United States has become an

increasingly difficult situation to combat. To put it in perspective, Jen Christensen and Sergio

Hernandez compare the heroin crisis to the HIV epidemic when the United States had no

treatment to turn to (2017). Contrary to popular belief, however, both researchers claim that the

increase in heroin use has spread so drastically due to the use in small towns and rural areas

compared to industrial and urban areas (Christensen & Sergio 2017). No longer is this an issue

that solely affects large cities across America. In fact, West Virginia, New Hampshire, and

Kentucky were the top three states with the most overdoses in the entire country (Christensen &

Sergio 2017). West Virginia alone holds six of the twenty counties in the country that have the

most heroin overdoses (Christensen & Sergio 2017). Additionally, updated research has

introduced that minority groups are no longer the group affected most by the epidemic; it is

white Americans that are using heroin the most. The heroin epidemic extends beyond the classic

minority race stigma; this is an issue that affects individuals from all races nationwide. In a study

done by the Department of Psychiatry at the Washington University in St. Louis, it was found

that heroin use has evolved from an “inner-city, minority-centered problem” and developed into

a issue involving “white men and women...living outside of large urban areas” (Cicero et. al

2014). The impact of this epidemic is enormous and it is reaching men and women across the

country in every age, race, and socioeconomic status. It has become increasingly clear that this

issue must be reviewed and resolved in order to prevent the overdoses of addicted Americans.

But what happens to the individuals who are not aware of the repercussions of their choice to use

heroin? In this paper, the causes and effects of a heroin addiction on a person’s life are discussed

in order to reveal why individuals choose to alter their lives to get high. This subject is extremely
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relevant to society today, as this issue has transitioned from a nationwide epidemic focused less

on race and socioeconomic status, and more on opioid prescriptions and biological dependence.

Given that more individuals are becoming influenced by heroin, it is imperative that citizens

nationwide should become informed on the detrimental effects of a heroin addiction.

Mental Causes of Heroin Addiction

While the recent phenomenon of prescribed opioids has played a major role in the

increase of nationwide heroin addictions, research about the biological causes of addicts provide

inside on the reasoning behind the exponential use of heroin and heroin addictions in the United

States. In an article designed for nurses treating patients with addictions, Georgina Casey

describes the biological causes and effects of substance abuse and addiction. Casey claims that

drug use causes “changes in the brain that lead from recreational use to addiction, and the

neurological mechanisms underlying relapse” (2017). As the brain becomes comfortable with the

use of a drug, it often changes and starts to become dependent upon the chemically altering

substance. She explains the debate between “addiction” and “dependence” within the DSM-IV

and discusses the two types of dependence that occur within an addiction. Physical dependence

occurs due to “repeated use of many chemical substances” that cause tolerance to said substances

(Casey 2017). As a result of continuous use of a drug, individuals experience withdrawal

symptoms. Similar to physical dependence, psychological dependence refers to the actual

cravings and individual experiences as a result of the repeating use (Casey 2017). Due to brain

cravings, addictions are often hard to get rid of. More often than not, the cravings and

withdrawal symptoms make it harder for addicts to make the switch to sober. While these

symptoms play a major role in drug addiction, Casey also discusses the dopamine theory on how

individuals become easily addicted as a result of involuntary mental reinforcement practices.

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In this theory, dopamine release along this pathway triggers sensations of

reward and pleasure. Illicit drugs work by increasing firing of dopaminergic
neurons, or inhibiting the breakdown or reuptake of dopamine, once it is
released into the synapses. Stimulant drugs act directly on the mesolimbic
system to produce their effects, but other drugs of abuse, as well as activating
this pathway, have their primary actions in other regions of the brain.

While some studies show that opioids do not have a large effect on the dopamine release process,

it is clear that other brain regions are involved. Drugs often have the tendency to overpower the

chemicals in the brain, causing an unstable reuptake of certain neurons, making the repetition of

drug use comma before an addiction has even begun. In her article, Georgina Casey describes the

insula, which feeds into both the amygdala and prefrontal cortex (2017). The insula interprets

“stress, sleep [deprivation], and drug deprivation and cause impulsive behavior when these

sensations are not accurately maintained (Casey 2017). To compare to Casey’s research, a group

of researchers at the Ningbo Addiction Research and Treatment Center in China tested the effect

of a drug addiction on the levels of the dopamine receptor D4 methylation. In general, higher

dopamine levels in a person’s brain causes the need for higher reinforcement from a substance,

causing dependence on drugs that give the brain an elated sensation. Within their study, there

were 60 individuals addicted to either heroin or methamphetamine and 52 individuals used as a

control (Ji 2017). As stated in their results, “DRD4...methylation levels were significantly higher

in all heroin and meth addicts compared with 52 controls” (Ji 2017). It was also stated that males

who were addicted to either drug were more likely to have increased methylation levels as well

(Ji 2017). Therefore, addicts typically have increased levels of dopamine and according to their

study, this is more prominent in male users. Compared with the 2017 article by Georgia Casey, it

can be inferred that dopamine levels do play a role in the causes of a heroin addiction. As

dopamine levels increase, it is predicted that the likelihood for addictions can increase. Acting as

basic human quality, all races and individuals from socioeconomic statuses experiences this;
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therefore, the dopamine theory disproves the common urban, low-income stigma that addictions

are formed based upon who you are and where you live. While the dopamine theory is an

impressive observation about the causes of addiction, this is not the only feasible theory on why

and how individuals become addicted to quickly to a drug such as heroin.

In an article analyzing the heroin epidemic from the lenses of three historic psychologists,

Nancy Dyer introduces the short and long term effects as well as the causes of addiction from

their perspective. Dyer questions how the symptoms can get as worse as “skin crawling”, but

people are still willing to put their lives through an addiction (2004). Such powerful drug

addictions tend to be aided by the biological expectancy for dependence. Accepting this fact, she

explains her ideas on the concept of causes of addiction as she states:

It is no wonder that this euphoria is found to be so compelling psychologically

and physically; after all, pain and pleasure are our most primal motivators.
Thus, the compulsion to use despite adverse consequences is fueled by very
basic brain functions, perhaps the most important elements to consider when
trying to understand why someone would use such a dangerous, addictive
substance.

Coming off of a drug as powerful as heroin can be nearly impossible once the brain

acknowledges its neuramic effects. Dyer also references Emile Durkheim who explains addiction

in two ways: “collective effervescence and amonie” (Dyer 2004). Emile Durkheim compares an

addiction to a “religious ritual” where individuals use drugs like heroin to find peace just as

many turn to their religion to find peace (Dyer 2004). In many ways this is true, relating to the

dopamine theory, where the drug supplies feelings of euphoria for the user. Dyer claims that

Durkheim’s quote, “religion, or some substitute for it, will always be with us”, is an omen for

current substance abuse within society (Dyer 2004). With the current stigma of correlating race

and class to causation of addition, society will deem the heroin epidemic as less credible in areas

such as West Virginia and New Hampshire, who suffer some of the worst levels of heroin users
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and overdoses across the nation. Due to not only biological causes of addiction, but also the

increase of prescription opioids as painkillers, the levels for all individuals increase daily as the

epidemic continues to plaque many within the United States.

Prescription Causes of Heroin

As society continues to prescribe pain relieving opioids for medical purposes, the stigma

between prescription drugs and heroin use has increased. After coming off of surgeries and other

painful health issues, many patients turn to opioids after their prescription is up. However, heroin

often becomes a more viable source of a high because of lower costs and easy accessibility. Due

to the prescription drug to heroin addiction pipeline, more Americans nationwide are becoming

exposed to outlets to begin addictions. Regardless of race or socioeconomic status, Americans

everywhere can easily obtain heroin, therefore, easily causing sources of addictions in a variety

of individual backgrounds. According to a study from the Department of Psychiatry at

Washington University, there is “growing evidence that some prescription opioid abusers,

particularly those who inhale or inject their drugs, graduate or shift to heroin...because it has

become more accessible and far less expensive than prescription opioids” (Circeo et. al 2014).

Researches in this study interviewed addicts through two different programs: Survey of Key

Informants’ Patients Program (SKIP) and Researchers and Participants Interacting Directly

(RAPID) program. Specifically within the RAPID interviews, “every respondent”, which

consisted of over 150, “who indicated heroin as their primary drug also endorsed lifetime abuse

of prescription drugs” (Cireco et. al 2014). Additionally, 94% of participants said they chose

heroin simply because it is cheaper and easier to find than prescription drugs (Cicero et. al 2014).

Represented by such a large amount of respondents in their research, it is obvious that

prescription opioids can act as a gateway into a heroin addiction. In their final discussion of the
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study, they noted the heroin crisis has become a major issue due to three primary reasons: the

misuse of prescription opioids, the common use of individuals using other opioids after

prescriptions, and the easy availability of heroin compared to prescription pills (Circeo et. al

2014).

To counteract the prescription to heroin theory, Jacob Sullum writes to prove that the

opioid crisis has nothing to do with the use of prescription pills. In his article “Don’t Blame Pain

Pills for the Opioid Crisis”, he explains a viewpoint that is not so typical in this field. Sullum

states that opioid addictions and deaths have little to do with prescriptions, but more to do with

“multi-drug users with histories of substance abuse and psychological problems” (2018). He

references a 2015 review between the prescription to opioid addiction pipeline. In the study,

former patients treated with narcotics were followed for thirteen years, yet only 1 in 550

individuals died from an overdose related to opioids (Sullum 2018). Throughout the article,

Sullum argues that overdose occur less from former treatment and more from past decisions to

experiment with illegal narcotics. While Sullum’s viewpoint counteracts those of Cicero and his

counterparts, his admits that the true cause of an opioid addictions occurs from past drug use.

Thus supporting the increasingly modern view of causes pertaining less to race and

socioeconomic status, and more to previous drug use and biological dependence.

Effects and Implementations of Treatment Heroin Addictions

Similar to the causes of addictions, the effects tend to vary from addict to addict.

Depending on the person, an addict will either admit themselves into a type of treatment or

overdose. In 2014 alone, 10,574 out of the 28,647 opioid related deaths were from heroin

(Christensen & Sergio 2017). As the heroin epidemic has spread and the number of overdoses

have increased, more treatment options have arised for struggling addicts.
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Beginning in the late 1960’s, the use of methadone to treat heroin became commonplace.

Even currently, many treatment centers give heroin users methadone to wean them off of their

addictions and prevent harsh withdrawal symptoms. Charles O’Brien writes,

If tolerance and withdrawal symptoms were the only elements of addictive

illness, treatment would simply consist of detoxification, a process that allows
the body to cleanse itself while receiving descending doses of a medication that
reduces withdrawal symptoms…[However], the more difficult aspect is the
prevention of relapse to drug-taking behavior...transfer from a short-acting drug
such a heroin to a longer acting drug such as methadone provides a smooth
transition to the drug-free state.

While the use of methadone is not an end-all-be-all, it does provide an easy transition from the

use of heroin. According to an article written in 1967, it was found that a 100mg dose of a

methadone “blockade” was equivalent to the “euphoric action of 80mg or more of heroin” (“New

Treatments for Heroin Addiction”). The same article also recommended the use of cyclazocine

where 4mg challenged 15mg of heroin (“New Treatments for Heroin Addiction” 1967). Around

the same time period, a study was done through the Black Action Methadone Program that tested

the outcomes of addicts who were treated with methadone and social services compared to those

with no treatment. The 223 patients in this program were predominantly black and white males

aging from 18-71 years (Cleveland et. al 1974). After analyzing the retention in program, relapse

on heroin, employment, and arrests one year after their admission, the program featured a

successful treatment rate for 76.6% of the former addicts (Cleveland et. al 1974). Due to the use

of methadone to control heroin addictions, patients in this program were able to end their

addictions and look for employment.

While methadone has been tested and established as an effective form of treatment for

heroin users, many researchers argue that long-term social programs are paramount for success

in addicts. In a 2015 study completed in Bologna, Italy, Raimonda Pavarin researched the
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standardized mortality ratios between public treatment center patients and non public treatment

center patients. The Standardized Mortality Ratio (SMR) is based on the deaths found in a study

compared to the average number of deaths that would be expected (Paravin 2015). The study was

completely voluntary and featured 959 subjects from age 15 to 64 (Paravin 2015). Paravin states,

“448 subjects went to a PTC...434 went to an emergency department… and 77 were admitted to

the hospital” 2015). Individuals treating in the public treatment center experienced 18 deaths

compared to 29 deaths within the non-PTC group (Paravin 2015). After following the PTC

subjects, over 24% successfully completed the treatment, 61% remained in therapy, and 14.7%

ended their treatment entirely (Paravin 2015). The study was concluded with the suggestion to

treat addictions from a large population scale compared to small and specific groups of

individuals with heroin addictions (Paravin 2015). While this study proved effective for a

number of addicts, working with large groups may not always create successful outcomes. In

fact, many addicts thrive knowing they have the full attention from their supporters. Without

feeling cared for and appreciated during the process, addicts will not be able to overcome the

mental urge to relapse. John Owens supports this idea with his personal viewpoint of effective

treatment for heroin users. He claims that there must be a “therapeutic team which will aim at a

long-term continuous sympathetic contact with the individual patient” (1967). This team must

include doctors, a social worker, a psychologist, probation officer, occupational therapist, and a

clinical pathologist who will work united together in order to come up with the best solution for

the individual (Owens 1967). In a facility such as the one Owens proposes, an addict is much

more likely to successfully overcome their struggle with heroin and opioids. In order to combat

the heroin epidemic, programs like these are necessary for change. Implemented in an effective

and neat manner, these programs have the power to change the lives of addicts with no other
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options. To compare with Owen’s point of view, Charles O’Brien states that “the treatment of

addicted patients must always be individualized” (2008). O’Brien also believes in the power of

mental and behavioral treatment in addition to medical detoxification. He claims that the “key to

successful treatment is long-term prevention of relapse by behavioural and pharmacological

means” (2008). With a balance between the two, heroin addicts should receive effective

treatment powerful enough to combat their previous urges.

ORBIT Correctional Program

Local to Henrico County, Virginia, the ORBIT Program represents an ideal image of a

balance between medical and behavioral treatment. Featuring 137 inmates in both jails in

Henrico, the program includes a four-step process to not only end addictions, but also start new

beginnings for the participants’ lives. The first step in the program is called “Rise”. This step

features two phases of recovery, that aim to detoxify and adjust the participant into jail life.

During this step (and throughout all steps), the participants are involved in numerous relapse

prevention and coping classes as well as groups that allow them to share their experiences with.

The second step features the “green team” where inmates work inside of the jail to demonstrate

commitment and responsibility. Those who move onto step two are well-trusted and allowed

minimum security in the jail. The third step is a major turning point for the inmates in this

program. When reaching this step, participants are able to leave the jail on work release where

they find real jobs to save up their money as well as attend therapy groups outside of the jail.

Leaving the jail creates a lot of trust between the correctional officers and the inmates. Finally,

the fourth and final step for this program is home incarceration.

When interviewing two women in the program, Nora Burnette and Lisa Harvey, it was

evident that the ORBIT program changed both of their lives. Nora Burnette explained that she
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“[did not] feel like [she] was an inmate” (personal communication, April 20, 2018). Burnette

talked through her story of opioid abuse and how she ended in the the ORBIT program. Before

she was arrested, she was “beyond control” and had lost grasps with her former life. She

explained how the classes, groups, and lessons learned in this program have “taught [her] not to

be triggered” and have given her hope for the future (personal communication, April 20, 2018).

Lisa Harvey shares a similar story about her alcoholism that lead her life astray. At the beginning

of her sentence, Harvey was “too proud to ask for help” (personal communication, April 20,

2018). However, after relapsing on home incarceration and returning to the ORBIT program, she

knew that it was time to take control of her addiction. A couple months into her second round of

the program, she began leading a Relapse Prevention group for participants at the jail. Harvey

explained that this was very “eye-opening” and helped with her own personal coping (personal

communication, April 20, 2018). Both women continuously repeated their gratitude for the

program and admitted that ORBIT saved their lives. Treatment programs such as ORBIT safely

and successfully improve the lives of struggling addicts who would otherwise be suffering in jail.

Conclusion

This paper alludes to the conception that the heroin epidemic in the United States has

reached a point where change must be instituted. Using a variety of research methods including

research journals and surveys, it has been found that heroin majorly affects the lives of addicts.

This subject is extremely relevant to society today, as the epidemic has transitioned from an issue

predominantly focused on race and socioeconomic status, to an epidemic caused by opioid

prescriptions and biological dependence. Given that more individuals are becoming influenced

by heroin, it is imperative that citizens nationwide should become informed on the detrimental

effects of a heroin addiction.

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Research List

Casey, G. (2017, September). Dealing with addiction. Kai Tiaki: Nursing New Zealand, 23(8),

20+. Retrieved from

http://link.galegroup.com/apps/doc/A507185361/GPS?u=henrico&sid=GPS&xid=ece33b

a4

Christensen, J. & Hernandez, S. (2017, June 23). This is america on drugs: A visual

guide. CNN. Retrieved from

https://www.cnn.com/2016/09/23/health/heroin-opioid-drug-overdose-deaths-visual-guid

e/index.html

Cicero T. J., Ellis M.S., Surratt H.L., & Kurtz S.P. (2014). The changing face of heroin use in the

united states: A retrospective analysis of the past 50 years. JAMA Psychiatry;

71(7):821–826. Retrieved from

https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1874575?;resultClick=3
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Cleveland W. H., et. al. (1974). Outcomes of methadone treatment of 300 innercity addicts.

Public Health Reports, 89(6), 563-568. Retrieved from

http://www.jstor.org/stable/4595122

Dyer, N. O. A. K. (2003). Durkheim, mead, and heroin addiction. Human Architecture: Journal

of the Sociology of Self-Knowledge, 2(2), 99+. Retrieved from

http://link.galegroup.com/apps/doc/A227788678/GPS?u=henrico&sid=GPS&xid=77d9b

18b

Ji, H., et al. (2018). Dopamine receptor d4 promoter hypermethylation increases the risk of drug

addiction. Experimental and Therapeutic Medicine, 15(2), 2128+. Retrieved from

http://link.galegroup.com/apps/doc/A525840893/GPS?u=henrico&sid=GPS&xid=320a2

34e

“New treatments for heroin addiction” (1967). The British Medical Journal, 2(5552), 588.

Retrieved from http://www.jstor.org/stable/20388227

O’Brien C. P. (2008). Evidence-based treatments of addiction. Philosophical Transactions:

Biological Sciences, 363(1507), 3277-3286. Retrieved from

http://www.jstor.org/stable/20208741

Owens, J. (1967). Centres for treatment of drug addiction: Integrated approach. The British

Medical Journal, 2(5550), 501-502. Retrieved from http://www.

jstor.org/stable/20388077

Sullum, J. (2018, February). Don’t blame pain pills for the opioid crisis. Reason, 49(9), 15.

Retrieved from

http://link.galegroup.com/apps/doc/A522210607/GPS?u=henrico&sid=GPS&xid=9ed64a

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